CLM-2026-023188
Canyon Clinical Laboratories, Clinical Laboratory. Service 2026-01-21 at independent laboratory (POS 81). Received 2026-03-01.
Member
Resolved through the identity graph
- Member
- Hiroshi Burns
- Member ID
- UHC-11947-28
- Date of birth
- 1958-03-23
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-408090
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5518
- Coverage period
- 2024-01-01 to present
- Deductible
- $487.57 of $1,500.0033%
- Out-of-pocket maximum
- $227.67 of $6,000.004%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 3883165920
- Network
- In network
- Rendering NPI
- 3883165920
- Location
- Charlotte, NC · TIN 14-6212435
- Authorisation / referral
- none / REF782185
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 85025 | Complete blood count with differential | — | 1 | 1 | $66.00 | $40.92 | $40.92 | $0.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | 25 | 1 | 2 | $64.00 | $39.68 | $39.68 | $0.00 | Paid |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $62.00 | $38.44 | $38.44 | $0.00 | Paid |
| Totals | $192.00 | $119.04 | $119.04 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-939468
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010946 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-21: CORE-HMO (HMO), effective 2024-01-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Canyon Clinical Laboratories (3883165920). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Clinical Laboratories2026-01-21 12:22
Patient seen for essential (primary) hypertension. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-03-01 02:33
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-939468.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013813 | 2026-01-29 | Lakeside Physical Therapy | $299.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.